CI claim – Case 1 56 years old, clean medical history CI policy issued 14.01.1999 at standard rate 28.12.2000: severe chest pain admitted to the CCU (Dr. Q, Cardiologist) > CI claim for Heart Attack What do you do?
CI Definition for Heart Attack > The first occurrence of heart attack or myocardial infarction which means the death of a portion of the heart muscle, as a result of an acute interruption of blood supply to the myocardium. > The diagnosis must be based on a history of: *Typical chest pain *New ECG changes proving infarction * Diagnostic elevation of cardiac enzymes > Angina is specially excluded
CI claim – Case 1 APS of Cardiologist On and off chest pains for the last two weeks precipitated by effort relieved by rest PTA severe chest pain lasting for 30 mins associated with shortness of breath On admission – chest pain relieved with nitrate drip, EKG – ST depression with T wave inversion No enzymes done WHAT WILL YOU DO? DECIDE?
CI claim – Case 1 APS of Interventionist - Cardiologist Angiogram performed on the 7 th HD revealed 95% stenosis of the LAD, 50% stenosis of the distal RAD Angioplasty with stenting of proximal LAD Troponin levels (done on the day after angiogram) 1.0 (nv < 0.2) MDs diagnosis: Acute Myocardial Infarction SETTLE OR DENY ?
CI claim – Case 1 DECISION: Settle as Acute MI or Deny Claim? No EKG evidence Enzymes elevate but done only after PTCA – procedure could raise Trop T Chest pain typical relieved with nitrate drip and no recurrence DECISION?
CI claim – Case 1 POINTS OF ARGUMENT No EKG evidence non Q MI? Enzymes only after PTCA Trop T - 10 days Chest pain relievedTypical YOU DECIDE!
CI claim – Case 2 CI policy issued 23.3.1999 at standard rate 4.2.2000: headache and left side weakness (Dr. CB, neurologist) 36 years old, clean medical history > CI claim for stroke
CI Definition of Stroke A cerebrovascular incident which results in permanent neurological deficit. The diagnosis must be supported by new changes on CT or MRI scan. The diagnosis must be certified by a neurologist
CI Definition of Stroke Exclusions: o Infarctions of brain tissue or intracranial bleeding as a result of bodily injury caused by violent external means or accident, is specifically excluded. o Transient ischaemic attacks are excluded
CI Claim – Case 2 APS of Neurologist - December 1998: episode of headache, but no definitive diagnosis. - May 1999:headache with left-side weakness.
CI Claim – Case 2 Follow-up: Headaches resolved Left limbs recovered after 2-4 weeks with mild residual numbness of the left arm.
CI Claim – Case 2 CONSIDERATIONS: Doctor states that this is a permanent condition and it has persisted more than 180 days. MRA and Digital subtraction angiography revealed AV malformation DECISION?
CI claim – Case 2 MR angiogram of brain (5.2.2000) o Strongly suggestive of a venous angioma, an arteriovenous fistula is also a possibility o Cigar-shaped lesion (3x1 cm) in the right posterior parietal region:old hematoma Digital subtraction angiography (18.2.2000) - Right temporo-parietal arterio-venous malformation. YOU DECIDE!
CONCLUSION WARS HAD BEEN WAGED AND KINGDOMS HAVE FALLEN BECAUSE OF POOR OR INADEQUTE DEFINITION There is a need to review the definition for CRITICAL CONDITIONS
CONCLUSION CHECK FOR DIAGNOSTIC ACCURACY CHECK FOR NEGATIVE PROGNOSTIC INDICATORS ESTIMATE WITHIN SPECIFIC DIAGNOSTIC CATEGORIES CHECK FOR CO-MORBIDITY SPECIFIC ISSUES
Little knowledge is a dangerous thing so we attend conferences like this to learn more and live more dangerously Thank You !
CRITICAL DECISIONS ON CRITICAL CONDITIONS CLAIMS BY Emiliano B. Canonigo, Jr., MD., FPCP, FPCC
CI claim – Case 3 * Male / 54, CI cover since 1996 CI Claim for Brain problem Cognitive impairment since June 1998; Drug treatment with Aricept, stable condition since August 1999. Declining memory, personality change, increasing social withdrawal * Clinical diagnosis: Dementia, probably degenerative.
CI Claim – Case 3 Neuro-psychological report (3/6/1999). Test administered included tests of attention, memory and learning, visual- spatial function, and frontal fluency function: performance was below average overall. Given his successful vocational history and satisfactory work performance before the onset of his memory problem, the observed below average test performance is highly a reflection of his deteriorated cognitive functioning of recent onset. Suggestive of frontal dysfunction. Any reversible pathology should be ruled out.